Evolving concepts of diagnosis, pathogenesis, and therapy of Sj?gren's syndrome

Differences in diagnostic criteria for Sj?gren's Syndrome (SS) have led to confusion in the research literature and in clinical practice. A particular challenge is the clinical diagnosis of the patients with sicca symptoms, fibromyalgia, chronic fatigue, vague cognitive defects, and a low titer antinuclear antibody. Until recently, many of these patients would have been classified as primary SS using the European criteria. A suggested revision of the European criteria will require inclusion of anti SS-A antibody or characteristic minor salivary gland biopsy, leading to greater agreement between European and San Diego criteria. Recent studies have emphasized that lacrimal and salivary gland flow involves an entire "functional" unit that includes the mucosal surface (the site of inflammation), efferent nerve signals sent to the midbrain (lacrimatory and salvatory nucleus), efferent neural signals from the brain, and acinal/ductal structures in the gland. Thus, symptoms of dryness or pain can result from interferences with any part of this functional unit. The initiating antigens in SS remain unknown, but immune reactivity against SS-A, SS-B, fodrin, alpha- amylase, and carbonic anhydrase have been demonstrated in patients with established disease. The inflammatory process in the gland releases metalloproteinases that alter the relationship of epithelial cells to their matrix, an interaction that is necessary for glandular function and survival. Therapies for SS remain inadequate. In SS patients with immune-mediated extraglandular manifestation (ie, lung, kidney, skin, nerve), the therapeutic approach is similar to systemic lupus erythematosus, although these therapies have relatively little effect on tear or saliva flow.     

Is gatekeeping better than traditional care? A survey of physicians' attitudes

CONTEXT: Nearly all managed care plans rely on a physician "gatekeeper" to control use of specialty, hospital, and other expensive services. Gatekeeping is intended to reduce costs while maintaining or improving quality of care by increasing coordination and prevention and reducing duplicative or inappropriate care. Whether gatekeeping achieves these goals remains largely unproven. OBJECTIVE: To assess physicians' attitudes about the effects of gatekeeping compared with traditional care on administrative work, quality of patient care, appropriateness of resource use, and cost. DESIGN: Cross-sectional survey of primary care physicians SETTING: Outpatient facilities in metropolitan Boston, Mass. PARTICIPANTS: All physicians who served as both primary care gatekeepers and traditional Blue Cross/Blue Shield providers for the employees of Massachusetts General Hospital, Boston. Of the 330 physicians surveyed, 202 (61%) responded. OUTCOMES MEASURES: Physician ratings of the effects of gatekeeping on 21 aspects of care, including administrative work, physician-patient interactions, decision making, appropriateness of resource use, cost, and quality of care. RESULTS: Physicians reported that gatekeeping (compared with traditional care) had a positive effect on control of costs, frequency, and appropriateness of preventive services and knowledge of a patient's overall care (P<.001). They also felt that gatekeeping increased paperwork and telephone calls and negatively affected the overall quality of care, access to specialists, ability to order expensive tests and procedures, freedom in clinical decisions, time spent with patients, physician-patient relationships, and appropriate use of hospitalizations and laboratory tests (P<.001). Overall, 32% of physicians rated gatekeeping as better than traditional care, 40% the same, 21% gatekeeping as worse, and 7% were of mixed opinion. Positive ratings of gatekeeping were associated with fewer years in clinical practice, generalist training, and experience with gatekeeping and health maintenance organization plans. CONCLUSIONS: Physicians identified both positive and negative effects of gate-keeping. Overall, 72% of physicians thought gatekeeping was better than or comparable to traditional care arrangements.     

What significance to genotype changes have in diagnosis of malignant hyperthermia?

Malignant hyperthermia (MH) is a potentially fatal, inherited pharmacogenetic disorder characterised by a dysfunction of the intracellular calcium regulation. Linkage to DNA markers from the chromosome 19q12-13.2 region and the MHS-phenotype (MH susceptible) has been shown in about 50% of families with a history of MH. The ryanodine receptor gene encoding the human skeletal muscle ryanodine receptor has been localised to the chromosome 19q13.1-13.2 region. The ryanodine receptor, which is an intracellular calcium release channel, has been proposed to be one of the candidate structures for the MH defect. At present, eight different single point mutations have been identified in the human skeletal muscle ryanodine receptor gene in families with disposition to MH. The incidence of the various mutations has been reported as 2-10% each. A combination of different mutations within one pedigree has not been demonstrated. A few years ago, linkage of the MHS-phenotype to DNA markers from the chromosome 17q11.2-24 region was published by an American group. However, this observation has not been confirmed in any of the several European families susceptible to MH. Genes encoding for subunits of the dihydropyridine receptor and the sodium channel of the human skeletal muscle have been found to be located in the chromosome 17q11.2-24 region which, in fact, could be additional candidates for the MH defect. The dihydropyridine receptor is linked to the ryanodine receptor and involved in the calcium regulation of skeletal muscle. Very recent studies have shown linkage to DNA markers from chromosome 7q- and chromosome 3q13.1 regions and the MHS phenotype in two distinct families with history of MH. However, the relevance of this observation is so far unknown. At present, unambiguous preoperative screening of MH disposition based on molecular genetic characteristics is not available because of the enormous heterogeneity of the human MH syndrome. Thus, the halothane-caffeine in-vitro contracture test according to the standard protocol of the "European MH Group" must be performed in order to discover MH susceptibility.     

"Delayed rupture of the spleen" or delayed diagnosis of the splenic injury?

Splenic rupture is the most frequent intraabdominal injury following blunt abdominal trauma. Massive hemorrhage commonly occurs from injuries to this friable vascular organ. The mortality rate from simple splenic rupture is 1%. Delayed diagnosis of a ruptured spleen increases the rate to 10%. During 1964-79, 293 patients underwent splenectomy for blunt splenic injury, of whom 278 were operated on within 24 h. All had typical signs of splenic lacerations with intraperitoneal bleeding from the time of injury. Fifteen patients were operated on more than 48 h after sustaining the injury. A detailed analysis of these 15 patients revealed that in only three did the evidence support delayed hemorrhage following traumatic rupture of the spleen. In the other 12 patients, there was a delay in recognition of the intraabdominal injury, almost entirely the result of "diagnostic error." Careful clinical inquiry and peritoneal lavage are the mainstays of early diagnosis and therapy and should help to eliminate any delay in the diagnosis of a ruptured spleen.     

Assessing quality of care via HEDIS 3.0. Is there a better way?

Patients, employers, and third-party payers are all calling for improved measures of health care quality. This has led to the development of "report cards," assessments that are many times applied not just to health plans but also to providers. One attempt at creating a standardized set of quality and effectiveness measures is the Health Plan Employer Data and Information Set (HEDIS). The HEDIS measures are based primarily on analyses of administrative data sets. Problems with HEDIS measures, including the probability that plans will use different data collection methods and a lack of risk adjustment, may result in incorrect conclusions about the quality of care delivered by various providers. An alternative method of standardized surveys is proposed that will overcome many of the limitations of the current HEDIS measures, provide outcome rather than process data, and provide data for developing interventions to improve quality.     

Are they really that happy? Exploring scale recalibration in estimates of well-being.

Objective: The authors addressed a lingering concern in research on hedonic adaptation to adverse circumstances. This research typically relies on self-report measures of well-being, which are subjective and depend on the standards that people use in making judgments. The authors employed a novel method to test for, and rule out, such scale recalibration in self-reports of well-being. Design: The authors asked patients with chronic illness (either lung disease or diabetes) and nonpatients to evaluate quality of life (QoL) for the patients' disease. In addition, the authors also asked them to rank and rate the aversiveness of a diverse set of adverse circumstances, allowing examination of both the numerical ratings and ordering among items. Main Outcome Measures: The authors compared patients' and nonpatients' ratings and rankings for the patients' disease and other conditions. Results and Conclusion: The authors found that patients not only assigned higher numerical QoL ratings to their own disease than did nonpatients but also ranked it higher among the broad set of conditions. These results suggest that scale recalibration cannot account for discrepant QoL ratings between patients and nonpatients. More generally, this study presents a new approach for measuring well-being that is not subject to the problem of scale recalibration. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

For better or worse? Coregulation of couples’ cortisol levels and mood states.

Although a majority of adults live with a close relationship partner, little is known about whether and how partners’ momentary affect and physiology covary, or “coregulate.” This study used a dyadic multilevel modeling approach to explore the coregulation of spouses’ mood states and cortisol levels in 30 married couples who sampled saliva and reported on mood states 4 times per day for 3 days. For both husbands and wives, own cortisol level was positively associated with partner’s cortisol level, even after sampling time was controlled. For wives, marital satisfaction weakened the strength of this effect. Partner’s negative mood was positively associated with own negative mood for both husbands and wives. Marital satisfaction fully moderated this effect, reducing the strength of the association between one’s own and one’s partner’s negative mood states. Spouses’ positive moods were not correlated. As expected, within-couple coregulation coefficients were stronger when mood and cortisol were sampled in the early morning and evening, when spouses were together at home, than during the workday. The results suggest that spouses’ fluctuations in negative mood and cortisol levels are linked over several days and that marital satisfaction may buffer spouses from their partners’ negative mood or stress state. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

RVU Task Force report: does it really reflect the current methods of practice?

The ODA in a publication in December 1996 gave two reasons for commissioning this study. 13 First, over the years a number of anomalies had crept into the Fee Guide and needed to be addressed. For instance, code 14301 (motivation of a patient with a bad habit) had a higher responsibility than a root canal treatment code. The second reason was to keep the guide reflective of the current methods of practice of dentistry. These are very noble ideals and unfortunately they were not achieved with the publication of this report. I have provided a few examples of times and responsibility which are not in keeping with the current methods of practice of dentistry. Common sense along with the scientific literature bears this out. The report is filled with inaccuracies and anomalies. In numerous instances there are procedures with times that would not allow for the provision of quality care. One over riding concern is that only 100 procedures had their times directly measured and the remaining 1,100 procedures had their times extrapolated from these measured times. If any of these 100 measured times are inaccurate or do not reflect the current methods of practice, then the extrapolated times will also not be correct. The RVU Task Force has asked for input from the membership. Copies of the report were initially only distributed in limited numbers to the Dental Societies and not to the membership at large. The membership could request additional copies and was given three months to prepare and submit a response on prepared feedback forms. The Task Force received feedback from over 300 members. They now claim that this feedback has generated extensive changes in the diagnostic and restorative sections, recall packages, the endodontic section and fixed and removable prosthodontics. 14 There appears to have been major changes throughout the entire report. How can one then claim that the report was scientifically done or that it produced valid results? How are we sure that these 300 members actually reviewed each and every one of the times and "R" factors for all 1,200 procedures in the Fee Guide? Does this input from the membership now create a valid study? Do these subsequent changes alter the supposed "scientific" underpinning of the RVU Report? Are we sure that these changes will now create a document that meets the objectives of this study? Why should the membership have to review, critique and fix a report that had numerous glaring flaws from its outset? Why must the membership of the Ontario Dental Association and every practicing dentist in Ontario be subjected to the ramifications of this flawed and inaccurate report? The final report will be available prior to the General Council Meeting of the Ontario Dental Association in May 1997. I urge every member to read and review the entire report to see if it meets the objectives of the Task Force. From reviewing the Draft Final Report of the RVU Task Force, and the proposed changes, I would strongly urge all members of the General Council of the Ontario Dental Association to reject any implementation of this report.     

Neutrophilia of infection/inflammation: are we really dealing with "inflamed" leukocytes?

We adopted whole blood flow cytometry and direct labeling of the CD11b/CD18 and CD62L antigens to study the relationship between their expression and leukocytosis in patients with infection/inflammation, acute stress and healthy volunteers. Mean +/- S.D. channel fluorescence intensity of CD11b/CD18 antigen on peripheral blood polymorphonuclears did not differ between patients with infection/ inflammation (173+/-78) and controls (167+/-72), but was significantly (p = 0.04) reduced in stress (135+/-60). No correlation was found between CD11b/CD18 antigen level and either polymorphonuclears absolute number or serum C-reactive protein. A significant negative correlation was noted between CD62L antigen expression on polymorphonuclears and their absolute number. We assume that cells with increased CD11b/CD18 surface concentrations are retained in the capillaries and that part of the leukocytes in the peripheral blood are stressed leukocytes with reduced CD11b/CD18. Thus, leukocytes detected in peripheral blood are not necessarily the most "inflamed" ones.     

What do psychotherapists really do in practice? An Internet study of over 2,000 practitioners.

Over 2,200 North American psychotherapists completed a Web-based survey concerning their clinical work, including theoretical orientation, client characteristics, and use of specific psychotherapy techniques. Psychotherapeutic integration was common, with the majority of respondents identifying with more than one theoretical orientation or as having an eclectic orientation. The modal patient was a White female adult suffering from a mood or anxiety disorder and interpersonal problems. Individual psychotherapy was the preferred treatment modality. The most frequently endorsed techniques were relationship-oriented such as conveying warmth, acceptance, understanding, and empathy. The least frequently endorsed techniques were biofeedback, neurofeedback, body and energy therapies, and hypnotherapy. Efforts to disseminate empirically based therapies require understanding and accommodating clinicians' tendencies to integrate techniques. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is decision making really impaired in eating disorders?

Objective: Decision making has been reported to be reduced in eating disorders. However, studies are sparse and have been carried out in various selected populations. In the current study we arranged to confirm previous observations and to assess the relationship between decision making and dimensions relevant to eating disorders. Method: Patients suffering from anorexia nervosa (n = 49), bulimia nervosa (n = 38), and healthy controls (n = 83) were assessed using the Iowa Gambling Task (IGT). All patients were euthymic and free of psychotropic medication. Self-questionnaires (Eating Disorder Inventory–2; Gardner, 1991; and Eating Attitude Test; Garner & Garfinkel, 1979) were used to assess clinical dimensions relevant to eating disorders. Results: No significant differences in IGT performance were observed between patients and healthy controls or between restrictive and purging types of anorexia nervosa. No correlations were found between IGT performance and eating disorder questionnaires. Conclusion: These results do not support reduced decision making in patients with eating disorders, and suggest that previously reported alterations could be related to other clinical characteristics. This should stimulate new topic-related studies designed to reach a firm conclusion. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Active learning: When is more better? The case of resident physicians’ medical errors.

An active learning climate facilitates new knowledge acquisition by encouraging employees to ask questions, seek feedback, reflect on potential results, explore, and experiment. These activities, however, also increase a learner’s chances of erring. In high-reliability organizations, any error is unacceptable and may well be life threatening. The authors use the example of resident physicians to suggest that by adjusting the conditions of priority of safety and managerial safety practices, organizations can balance these potentially conflicting activities. Participants in the study were 123 residents from 25 medical wards. Results demonstrated that the positive linear relationship between priority of safety and safety performance, demonstrated in earlier studies, existed only when the active learning climate was low. When the active learning climate was high, results demonstrated a U-shaped curvilinear relationship between priority of safety and number of errors. In addition, high managerial safety practices mitigated the number of errors as a result of the active learning climate. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Why attend school? Chinese immigrant and European American preschoolers' views and outcomes.

The developing views of the purposes of school learning (PSLs) and related achievement among immigrant Chinese preschoolers and their European American (EA) age-mates were examined. Both culture and socioeconomic status (SES) were considered simultaneously, an often neglected research approach to studying Asian children. One hundred and fifty 4-year-olds—50 each of middle-class Chinese (CHM), low-income Chinese (CHL), and EA children—completed 2 story beginnings about school and were also tested for their language and math achievement. Results showed that 4-year-olds held sophisticated PSLs, ranging from intellectual to social and affect benefits. Large cultural and SES differences also emerged. CHM children mentioned more adult expectation and seriousness of learning than EA children who expressed more positive affect for self and compliance with adults. CHL children mentioned fewest PSLs. Achievement scores for oral expression of both immigrant groups were significantly lower than those of EA children despite similar reading and math achievement. Controlling for culture and SES, the authors found that children's articulated intellectual, but not other purposes, uniquely predicted their achievement in all tested domains. Cultural and SES influences on immigrant children are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ionising radiation in diagnosis: do the risks outweigh the benefits?

Every diagnostic test in medicine has costs and potential benefits. Doctors must ensure that the benefits of each test performed outweigh the costs, which include financial considerations and risks to the health of the patient. The possible adverse effects of some invasive tests such as biopsies may be well understood, but for others the risks are not so obvious or immediate. Seemingly "non-invasive" tests involve the use of ionising radiation and carry the risk of causing malignant tumours. This risk is widely underestimated in medical practice in Australia, and it is the responsibility of the radiological community to demonstrate that commonly performed investigations result in a net benefit to patients.     

Do "America's Best Hospitals" perform better for acute myocardial infarction?

BACKGROUND: "America's Best Hospitals," an influential list published annually by U.S. News and World Report, assesses the quality of hospitals. It is not known whether patients admitted to hospitals ranked at the top in cardiology have lower short-term mortality from acute myocardial infarction than those admitted to other hospitals or whether differences in mortality are explained by differential use of recommended therapies. METHODS: Using data from the Cooperative Cardiovascular Project on 149,177 elderly Medicare beneficiaries with acute myocardial infarction in 1994 or 1995, we examined the care and outcomes of patients admitted to three types of hospitals: those ranked high in cardiology (top-ranked hospitals); hospitals not in the top rank that had on-site facilities for cardiac catheterization, coronary angioplasty, and bypass surgery (similarly equipped hospitals); and the remaining hospitals (non-similarly equipped hospitals). We compared 30-day mortality; the rates of use of aspirin, beta-blockers, and reperfusion; and the relation of differences in rates of therapy to short-term mortality. RESULTS: Admission to a top-ranked hospital was associated with lower adjusted 30-day mortality (odds ratio, 0.87; 95 percent confidence interval, 0.76 to 1.00; P=0.05 for top-ranked hospitals vs. the others). Among patients without contraindications to therapy, top-ranked hospitals had significantly higher rates of use of aspirin (96.2 percent, as compared with 88.6 percent for similarly equipped hospitals and 83.4 percent for non-similarly equipped hospitals; P<0.01) and beta-blockers (75.0 percent vs. 61.8 percent and 58.7 percent, P<0.01), but lower rates of reperfusion therapy (61.0 percent vs. 70.7 percent and 65.6 percent, P=0.03). The survival advantage associated with admission to top-ranked hospitals was less strong after we adjusted for factors including the use of aspirin and beta-blockers (odds ratio, 0.94; 95 percent confidence interval, 0.82 to 1.08; P=0.38). CONCLUSIONS: Admission to a hospital ranked high on the list of "America's Best Hospitals" was associated with lower 30-day mortality among elderly patients with acute myocardial infarction. A substantial portion of the survival advantage may be associated with these hospitals' higher rates of use of aspirin and beta-blocker therapy.     

Restructuring Medicare for the next century: what will beneficiaries really need?

Medicare coverage falls short of its original mandate of access to modern medicine and protection against the high costs of medical care. These shortfalls destabilize both health outcomes and the economic viability of older adults and their families. Our proposed revisions would promote, rather than discourage, optimal care for beneficiaries. By replacing incentives for fragmented, episodic care with an orientation toward functional status, care management, and integration with long-term care, we can make an invaluable investment in a successfully aging society.     

Acts of will?

Discusses the articles contained in the present volume addressing the issue of will and the frequent disconnect between what people intend to do and what they actually do. The authors in the series suggest that people perceive themselves to have more control over everyday behavior than they actually do. The authors present a conceptual and empirical framework for understanding the causes of behavior for the times when it is recognized that "will" has broken down and people are unable to act as they desire. According to the authors, the source of behavioral control comes not from active awareness but from subtle cues in the environment and from thought processes and information not readily accessible to consciousness. The theory and data presented in these articles represent recent fundamental breakthroughs in the understanding of motivations, free will and behavioral control. The premise of the 4 articles is this: There are mental activations of which we are unaware and environmental cues to which we are not consciously attending that have a profound effect on our behavior and that help explain the complex puzzle of human motivation and actions that are seemingly inexplicable, even to the individual performing the actions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Exercise duration and mood state: How much is enough to feel better?

The effects of exercise duration on mood state were examined. In a repeated-measures design, the Profile of Mood States inventory (D. M. McNair, M. Lorr, & L. F. Droppleman, 1971) was administered before and after 1 quiet resting trial and 3 exercise trials of 10, 20, and 30 min on a bicycle ergometer. Heart rate levels were controlled at 60% of the participant's estimated V02max level. An overall analysis of variance found improved levels of vigor with reduced levels of confusion, fatigue, and total negative mood. Planned analyses revealed that the improvements in vigor, fatigue, and total mood occurred after 10 min of exercise, with progressive improvements in confusion over 20 min and with no additional improvement over longer periods. These results complement current recommendations, which suggest that to experience positive fitness and health benefits, healthy adults should participate in a total of 30 min of moderate physical exercise daily, accumulated in short bouts throughout the day. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is heavy drinking really associated with attrition from college? The alcohol-attrition paradox.

Student attrition at colleges across the United States poses a significant problem for students and families, higher educational institutions, and the nation's workforce competing in the global economy. Heavy drinking is a highly plausible contributor to the problem. However, there is little evidence that it is a reliable predictor of attrition. Notably, few studies take into account indicators of collegiate engagement that are associated with both heavy drinking and persistence in college. Event-history analysis was used to estimate the effect of heavy drinking on attrition among 3,290 undergraduates at a large midwestern university during a 4-year period, and student attendance at a number of college events was included as covariates. Results showed that heavy drinking did not predict attrition bivariately or after controlling for precollege predictors of academic success. However, after controlling for event attendance (an important indicator of collegiate engagement), heavy drinking was found to predict attrition. These findings underscore the importance of the college context in showing that heavy drinking does in fact predict attrition and in considering future intervention efforts to decrease attrition and also heavy drinking. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Choice-supportive source monitoring: Do our decisions seem better to us as we age?

Participants were given several 2-option choices and then asked to review how they felt about their decisions, to review the details of their decisions, or to do an unrelated task. When later asked to attribute features to the previous options, in each condition older adults (64–83 years) attributed significantly more positive and fewer negative features to their chosen options than to foregone options. Younger adults' (18–22 years) attributions were as choice-supportive as those of older adults in the affective review condition but were less so in the other conditions. The age difference was present even when older and younger adults were equated for source identification and recognition accuracy. This study suggests that as people age, their tendency to distort memory in favor of the options they chose increases. In addition, it suggests that affectively reviewing choices increases younger adults' tendency toward choice-supportive memory. (PsycINFO Database Record (c) 2010 APA, all rights reserved)